[A case of rectal cancer which showed complete response to chemotherapy for para-aortic lymph node metastases remaining after surgery, for which resection of Virchow's lymph node recurrence led to long-term survival].

A 55-year-old man with a positive fecal occult blood test visited our department, and after a thorough medical evaluation, was diagnosed with Stage IV Rs rectal cancer with marked para-aortic lymph node metastasis. In December 2007, the patient underwent low anterior rectal resection with D3 lymph node dissection, but the para-aortic lymph nodes were left. The metastatic lymph nodes showed a complete response(CR)to post-operative chemotherapy with FOLFOX, FOLFIRI, IRIS, and irinotecan+cetuximab, and the complete response was sustained for 18 months after surgery. Later, he developed Virchow's lymph node metastasis, which was also resected. At present, 5 years after the first surgery, the patient, whose chemotherapy has been discontinued, is alive without recurrence. It appears that using key drugs, such as 5-fluorouracil, leukovorin, oxaliplatin, irinotecan, and cetuximab, and performing aggressive salvage surgery for Virchow's lymph node recurrence, led to long-term recurrence-free survival.

A case of leptomeningeal carcinomatosis from esophageal basaloid carcinoma diagnosed by quantitative reverse transcription-polymerase chain reaction for carcinoembryonic antigen.

We describe herein the case of a 68-year-old man who experienced leptomeningitis after esophagectomy from an esophageal basaloid carcinoma. Although the patient had a good operative course for the first 10 days after surgery, he suddenly had general convulsions with unconsciousness. He was placed on mechanical ventilation in an intensive care unit. Computed tomography and magnetic imaging resonance did not reveal any abnormal findings. No abnormal data in the cerebrospinal fluid were found by biochemical, virological, and cytological examination. The positive expression of carcinoembryonic antigen messenger ribonucleic acid in cerebrospinal fluid was detected by a quantitative reverse transcription-polymerase chain reaction method. Immunohistochemical staining using an anticytokeratin antibody confirmed the presence of tumor cells in the cerebrospinal fluid. Spontaneous breathing was recovered after treatment with systemic chemotherapy. Six months after surgery, computed tomography revealed multiple brain metastases. This case demonstrates that the quantitative reverse transcription-polymerase chain reaction method of analyzing carcinoembryonic antigen messenger ribonucleic acid may be a sensitive and useful method for determining leptomeningeal metastasis before the detection of tumors by cytological and imaging examinations in patients with cancer.

Clinical implications of intratumoral dendritic cell infiltration in esophageal squamous cell carcinoma.

The clinical impact of intratumoral dendritic cell infiltration (IDCI) in esophageal cancer is not fully understood. We investigated the relationship between IDCI and clinical features in esophageal carcinoma. A retrospective analysis of a total of 203 patients who underwent esophagectomy for squamous cell esophageal carcinoma was performed. We evaluated IDCI immunohistochemically using S-100-protein. Under a high power objective (x400), we evaluated IDCI in 10 regions of surgical specimen including the most invasive slice and averaged the number of S-100-protein positive cells. The patients were classified into two groups according to IDCI (>20 or <20 S-100-protein positive cells per high power field: high or low IDCI, respectively). The degree of IDCI varied from 0 to 67 (average 12.3). The 203 patients were separated into 65 with high IDCI and 138 with low IDCI. The depth of invasion was significantly more superficial in patients with high IDCI (p<0.05), and the disease was at an earlier clinical stage (p<0.01) than in those with low IDCI. Five-year survival rates after curative resection were 67% and 39% in patients with high and low IDCI, respectively (p<0.01). Multivariate analysis showed that IDCI was an independent prognostic factor (RR=1.6, p=0.02), next to nodal involvement, depth of invasion and clinical stage. Being closely related to clinical features, the prognosis of patients with esophageal cancer may be estimated by monitoring IDCI.

Biologic and imaging diagnosis of lymph node metastasis in esophageal carcinoma.

BACKGROUND AND OBJECTIVES: Few reports have described the combined use of biologic and imaging techniques in the diagnosis of lymph node metastasis. We prospectively evaluated lymph node metastasis diagnosed by biologic and imaging means in patients with esophageal carcinoma. METHODS: Preoperative ultrasound and endoscopic ultrasound (EUS) examination were performed in 80 patients. Biopsy specimens were immunohistochemically examined using cyclin D1 (CD1) and desmoglein 1 (DG1) antibodies, and tumors were classified into three grades. RESULTS: The sensitivity, specificity, and accuracy values of ultrasound examination were 88.2, 58.6, and 77.5%, respectively. The incidence of nodal involvement was 0% (0/10) in patients with grade 1 tumors, 57.1% (16/28) in those with grade 2 tumors, and 83.3% (35/42) in those with grade 3 tumors. Of the 57 patients with lymph node metastasis determined sonographically, 50 had grade 2 or 3 tumors that were histologically confirmed. The remaining seven patients with grade 1 tumors did not have involved nodes. Of the 23 patients without lymph node metastasis according to ultrasound examination, the incidence of lymph node metastasis in patients with grade 1, 2, and 3 tumors was 0, 16.7, and 50.0%, respectively. CONCLUSIONS: When used together, imaging and molecular procedures may offer improved identification of lymph node metastasis in patients with squamous cell carcinoma of the esophagus.

Smad4 and transforming growth factor beta1 expression in patients with squamous cell carcinoma of the esophagus.

PURPOSE: The members of the Smad family play key rolesin regulating gene expression in the transforming growth factor (TGF)-beta1 signaling pathways. Activation of Smads causes their translocation from the cytoplasm to the nucleus, where they function as transcription factors. The present study analyzed the expression and clinicopathological significance of Smad4 and TGF-beta1 in squamous cell carcinoma of the esophagus. EXPERIMENTAL DESIGN: Immunohistochemistry was used to investigate the expression of Smad4 and TGF-beta1 proteins in 258 patients with squamous cell carcinoma of the esophagus. The relationship between expression of these proteins and clinicopathological factors was analyzed, and the usefulness of Smad4 in disease prognosis was evaluated in relation to TGF-beta1 expression. RESULTS: Smad4 expression was preserved in 32.2% of tumors, and TGF-beta1 expression was identified in 42.6% of tumors. Patients with preserved expression of Smad4 had a higher rate of early-stage carcinoma (P < 0.01) and fewer lymph node metastases (P < 0.01) than those with reduced Smad4 expression. The expression of TGF-beta1 was not associated with any of the clinicopathological factors. Postoperative survival analysis indicated that patients with a tumor in which Smad4 expression was reduced had worse clinical outcomes than those with preserved expression (P = 0.01). In patients with TGF-beta1-negative tumors, the survival rate was significantly higher in patients with a preserved level of Smad4 expression than in those with reduced Smad4 expression (P = 0.02). However, according to multivariate analysis, Smad4 expression could not be used as an independent prognostic factor. CONCLUSIONS: Although Smad4 expression could not be used as a prognostic factor, its expression reflected tumor progression such as tumor depth and lymph node metastasis.